PROFESSIONAL EXPERIENCE

Molina Healthcare

Appeals and Grievance Specialist

[June 2018 – June 2023]

Conducted thorough research and analysis of contractual benefits, limitations and exclusions and grievance cases to assist medical staff in resolving appeals and disputes over services

Performed accurate data entry for complex appeals and acted as a subject matter expert on policies and benefits

Worked on state fair-hearing proceeds to make final resolutions for denied services

Provided resolutions on complex government contracts within 24 hours of receipt

Utilized excellent written and verbal communication skills to interact with internal and external stakeholders while maintaining confidentiality of medical information

Discovery Health Partners

Investigative Team Lead

[June 2015 – June 2018]

Lead a team of 12 employees

Managed all aspects of team duties including but not limited to: answering team member questions, on-going training and development on safety practices and deadlines, and overseeing team member work for quality and guideline compliance

Assisted with monitoring, prioritizing and distributing work to the legal assistants and the subrogation team to maximize recovery

Prepared call trend data reports to management on a weekly basis

IlliniCare

Member and Provider Service Representative

[July 2013 – June 2015]

Responded to member inquiries regarding services and plan benefits

Coordinated with other departments to ensure the resolution of member and provider issues regarding any services provided and medical claims

Consistently met department goals related to quality and quantity of calls

Comcast

Inbound Sales Specialist/Peer Coach

[October 2008 – June 2012]

Met and exceeded sales quotas by generating sales from inbound calls

Provided exceptional customer service by interacting with customers, answering inquiries, and effectively handling customer issues

Maintained a working knowledge of Comcast products, industry information, and competitive landscape

Acted as a peer coach to new team members and assisted team leaders in resolving customer issues

SKILLS

Customer Service

Problem Solving

Training and Development

EDUCATION

University of Phoenix; Associates of Arts in Psychology, January 2008

LATESHA SWANIGAN

630-***-**** ad3hsj@r.postjobfree.com Romeoville, IL

Time Management

Planning & Organization

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